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NIH Rare Diseases:45 Herpes zoster oticus is a common complication of shingles,A an infection caused by the varicella-zoster virus (which is the virus that also causes chickenpox). Ramsay Hunt syndrome: A herpes virus infection of the geniculate nerve ganglion that causes paralysis of the facial muscles on the same side of the face as the infection. The classic presentation of BP is a patient with partial or complete weakness of the muscles on one half of the face. Several factors set the presentation of BP apart from other conditions that can affect the facial nerve. When considering the differential for BP, the history and physical will often be enough to exclude most of these conditions.
Bell’s palsy is a clinical diagnosis, which depends on the presentation and not clinical studies. Medical treatment for BP in the past has revolved around two medications: antivirals and steroids. Bell’s palsy is an idiopathic paralysis of the facial nerve and is the most common cause of lower motor neuron facial palsy.
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An important gene associated with Geniculate Herpes Zoster is MT-TC (Mitochondrially Encoded TRNA Cysteine), and among its related pathways are Primary immunodeficiency and amb2 Integrin signaling.
The patients also usually suffer from unilateral loss of taste, excessive tearing or dry eye, and hyperacusis. He states that over the past two days, he has had increasing difficulty moving the right side of his face. The innervation of the upper facial muscles is bilateral and that of the lower facial muscles unilateral.
The main diagnoses to consider when a patient’s presentation is suspicious for BP can be grouped into infectious, inflammatory, neoplastic, and cerebrovascular categories.1 This grouping is shown in Table 1. A history of hypertension, diabetes, smoking, dyslipidemia, or cardiovascular disease calls for close evaluation of other deficits.
The possibility of stroke in a patient presenting with what looks like BP must be considered and ruled out immediately. It is unilateral and acute in onset, progressing over a period of hours and reaching maximal intensity within several days.


Acute motor-sensory axonal Guillain-Barre syndrome with unilateral facial nerve paralysis after rotavirus gastroenteritis in a 2-year-old boy. Combined corticosteroid and antiviral treatment for Bell palsy: a systemic review and meta-analysis. The benefits of steroids versus steroids plus antivirals for treatment of Bell’s palsy: a meta-analysis. He first noticed his mouth drooping on the right side along with difficulty closing his right eye. Additionally, trauma can result in facial nerve palsy; this can be gathered from the history and will likely also be evident on exam.
Likewise, risk factors for HIV, such as IV drug use or risky sexual behavior, necessitates HIV testing. Presence of any of the factors warrants an evaluation for an underlying cause other than BP.
If a red flag is present, further testing including a complete blood count with differential, sedimentation rate, Lyme titer, thyroid function studies, and electrolytes is warranted.4 Intracranial imaging with CT noncontrast of the head should be obtained.
Ischemic stroke is the second leading cause of unilateral facial paralysis, behind BP.15 As previously stated, a common rule of thumb is that upper motor neuron lesions spare the forehead, which receives bilateral upper motor neuron innervation. These patients should be given lubricating eye drops for use during the day in addition to a corneal lubricant to use at night.4 Furthermore, patches or taping the eyelid closed can be used at night. He has no history of any previous episode like this, no past medical history, and no history of trauma. Unfortunately, despite what we are taught, complete unilateral facial paralysis does not exclude an intracranial process, and if the history or presentation is concerning for an upper motor neuron process the patient should receive further evaluation. Ultimately, what every physician is worried about missing is stroke or an intracranial process. Any history of a prior cancer or of facial palsy that progresses over weeks or months is concerning for either brain metastasis or expansion of an intracranial tumor.
On the other hand, lesions that affect the facial nerve after it exits the brainstem (such as BP) result in weakness of the entire ipsilateral face. The patient should be referred to an ophthalmologist if they experience ocular pain or develop any ocular complications.
Involvement of the forehead can be used as a baseline in differentiating lower versus upper motor neuron involvement.
When treatment is needed, medications such as antiviral drugs or corticosteroids may be prescribed.


Involvement of the parasympathetic fibers leads to decreased tear production and salivation. The physical exam will be enough to rule out Ramsay-Hunt Syndrome (which will present with an erythematous vascular rash in the ear) and otitis media (facial paralysis is a potential complication). However, this rule does not always hold true, as rarely ipsilateral pontine pathology (such as ischemia or mass) can lead to a lower motor neuron pattern of facial weakness.
When evaluating BP, any features concerning for an intracranial process such as a tumor or stroke warrant further consideration. I have heard of decompression surgery, but am not willing to go that route unless people are running away when they see me. Physical exam reveals complete paralysis of the right side of his facial muscles, though the rest of the neurologic exam is normal. Involvement of the afferent fibers from taste receptors leads to alterations and lack of taste sensation. In this case, dysfunction of the ipsilateral abducens nerve (resulting in lateral gaze palsy) will also be present, helping to differentiate a stroke of the ipsilateral pons from BP.1 In summary, when evaluating for stroke, take into account the overall clinical picture of the patient.
Furthermore, recovery rates were lower in the group receiving prednisolone and acyclovir compared to the group receiving prednisolone alone.17 A meta-analysis in 2009 examining use of corticosteroids alone vs. The initial portion of the facial nerve exiting the brainstem is called the cisternal segment.
While Guillain-Barre syndrome can present with facial weakness in up to 50% of patients,11,12 it is most commonly bilateral and occurs with symmetric muscle weakness and absent or decreased deep tendon reflexes.
The intracanalicular segment of the facial nerve runs in the anterosuperior quadrant of the internal auditory canal. The remainder of the segments include the labyrinthine, tympanic, mastoid, and extratemporal.
The prognosis of BP is excellent, with 85% of patients regaining function within three weeks.



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